[RDN] Payer-Specific Billing Guidelines

Summary

This document outlines Nutritional Counseling coverage criteria published by Aetna, Anthem BCBS, Cigna, Oscar, and UHC. Understanding these requirements will help you submit accurate claims and improve the likelihood of coverage.

Most payers require providers to submit:

• ICD-10 Code Z71.3 (dietary counseling and surveillance)

• Medical and/or BMI ICD-10 codes related to the condition being treated

Aetna

Aetna has a policy specifically for Nutritional Counseling. While they accept ICD-10 Code Z71.3 (dietary counseling and surveillance), providers must also submit the relevant medical and/or BMI ICD-10 codes associated with the patient’s nutritional services. These will be reviewed against Aetna's coverage policy.

Payer-considered indications include:

• Adult obesity
• Pediatric obesity
  • Age 19 or under
• Overweight adults with cardiovascular risk
  • Hypertension
  • Dyslipidemia
  • Metabolic diseases
  • Cardiovascular disease
  • Coronary artery disease
• Eating disorders
• Hypertension
• Kidney disease
• COPD
• Seizure disorders
  • Ketogenic diet
• Digestive system disorders

Exclusions include:

• ADHD
• Asthma
• Chronic fatigue syndrome

Anthem BCBS

Nutritional counseling criteria are part of Anthem’s preventive care programs. Anthem requires providers to submit both the medical and/or BMI ICD-10 codes along with ICD-10 Code Z71.3 (dietary counseling and surveillance).

Coverage details:

• Limited to 12 units per calendar or plan year
  • Combined total for CPT codes 97802 and 97803
• Coverage may vary by plan

Payer-considered indications include:

• Cardiovascular risk prevention
  • Cardiovascular disease
  • Diabetes
  • Pregnancy-related cardiac concerns
  • Hyperlipidemia
  • Hypertension
  • Kidney disease
• Obesity in adults
• Overweight adults
• Pediatric obesity
  • Under age 18
• Pre-diabetes prevention
• Healthy weight in pregnancy
• Type 2 diabetes prevention

Cigna

Cigna outlines criteria for Nutritional Counseling in their Preventive Care Policy. For preventive care, Cigna requires providers to define the type of visit being performed, ICD-10 Codes, like Z71.3 (dietary counseling and surveillance), define the type of visit that is taking place.Be sure to use the correct code to define the type of visit being performed, and remember, it is important to also submit the medical and/or BMI ICD-10 codes associated with the patient’s nutritional services.

Coverage details:

• Limited to 3 visits per year
  • Combined total for CPT codes 97802 and 97803

Payer-considered indications include:

• Cardiovascular risk prevention
  • Cardiovascular disease
  • Diabetes
  • Pregnancy-related cardiac concerns
  • Hyperlipidemia
  • Hypertension
  • Kidney disease
• Obesity in adults
• Pediatric obesity
• Pregnancy-related concerns

Oscar

Oscar has a policy for Medical Nutritional Therapy. Providers must submit both the medical and/or BMI ICD-10 codes along with ICD-10 Code Z71.3 (dietary counseling and surveillance).

Payer-considered indications include:

• Endocrine and metabolic disorders
• Eating disorders
• Seizure disorders
  • Ketogenic diet
• Hypertension
• Cardiovascular and coronary artery disease
• COPD
• Diseases of the stomach and esophagus
• Gastrointestinal disorders
• Endocrine organ disease
• Intestinal malabsorption
• Pregnancy concerns
• Overweight adults
• Adult obesity
• Pediatric obesity
• Underweight pediatric patients

Exclusions include:

• ADHD
• Asthma
• Chronic fatigue syndrome
• Depression
• Anxiety disorders
• Autism spectrum disorder
• Non-celiac gluten sensitivity

United Healthcare

UHC provides criteria for Nutritional Counseling in their Preventive Care Policy. Providers must submit both the medical and/or BMI ICD-10 codes along with ICD-10 Code Z71.3 (dietary counseling and surveillance).

Payer-considered indications include:

• Cardiovascular risk prevention
  • Cardiovascular disease
  • Diabetes
  • Pregnancy-related cardiac concerns
  • Hyperlipidemia
  • Hypertension
  • Kidney disease
• Weight loss for overweight and obese adults
• Obesity in children and adolescents
• Healthy weight in pregnancy
• Type 2 diabetes prevention